Molecular basis and enzymatic properties of glucose 6-phosphate dehydrogenase volendam, leading to chronic nonspherocytic anemia, granulocyte dysfunction, and increased susceptibility to infections.

We have investigated the blood cells from a woman with a low degree of chronic nonspherocytic hemolytic anemia and frequent bacterial infections accompanied by icterus and anemia. The activity of glucose 6-phosphate dehydrogenase (G6PD) in her red blood cells (RBCs) was below detection level, and in her leukocytes less than 3% of normal. In cultured skin fibroblasts, G6PD activity was approximately 15% of normal, with 4- to 5-fold increased Michaelis constant (Km) for NADP and for glucose 6-phosphate. Activated neutrophils showed a decreased respiratory burst. Family studies showed normal G6PD activity in the RBCs from all family members, including both parents and the 2 daughters of the patient. Sequencing of polymerase chain reaction (PCR)-amplified genomic DNA showed a novel, heterozygous 514C-->T mutation, predicting a Pro172-->Ser replacement. Analysis of G6PD RNA from the patient's leukocytes and fibroblasts showed only transcripts with the 514C-->T mutation. This was explained by the pattern of X-chromosome inactivation, studied by means of the human androgen receptor (HUMARA) assay, which proved to be skewed in the patient, her mother, and one of the patient's daughters. Thus, the patient has inherited a de novo mutation in G6PD from her father and an X-chromosome inactivation determinant from her mother, causing exclusive expression of the mutated G6PD allele. Purified mutant protein from an Escherichia coli expression system showed strongly decreased specific activity, increased Km for NADP and for glucose 6-phosphate, and increased heat lability, which indicates that the defective phenotype is due to 2 synergistic molecular dysfunctions: decreased catalytic efficiency and protein instability.

Remission of monoclonal chronic T-cell expansion associated with severe anemia.

A 49-year-old male with an 8 year history of lowered Hb level, granulocytopenia and fatigue presented in 1986 with progressive fatigue, a dramatically reduced Hb level (45 g/l) and an increased lymphocyte count (6.6 x 10(9)/l). Clinical picture and laboratory studies led to the diagnosis of chronic T lymphocytosis with expansion of CD8+ T cells expressing CD16 IgG Fc receptors (Fc gamma RIII). DNA analyzed with T-cell receptor (TcR) gamma and beta probes revealed extra rearranged bands representing a clonal expansion of T lymphocytes. These T lymphocytes expressed T-cell receptor alpha beta as evaluated by staining with monoclonal antibodies. Because of the severe progressive anemia the patient was transfused with packed red cells. He was then treated with cyclophosphamide. After one month of treatment the transfusions could be discontinued and two months later cyclophosphamide treatment was stopped because of normalized Hb level and lymphocyte counts. The patient remained in a hematologically stable condition, though a minor T-cell population representing the clonal expansion, an inverted CD4/CD8 ratio and low immunoglobulin levels persisted. This is the first report of regression of proven monoclonal CD8+ T gamma-cell expansion and the associated anemia following cyclophosphamide therapy. These observations implicate the expanded monoclonal CD8+ lymphocytes in the pathogenesis of the anemia and granulocytopenia.

Trisomy 13 and myelodysplastic syndrome.

The clinical and cytogenetic data of a patient with myelodysplastic syndrome-refractory anemia with excess blasts (MDS-RAEB) and trisomy 13 as the sole abnormality are presented. This appears to be only the second report of such a patient. The presence of trisomy 13 is confirmed by in situ hybridization using an alphoid repeat probe L1.26, which is specific for the centromeres of both chromosomes 13 and 21.

Hb J-Anatolia [alpha 61(E10)Lys----Thr]: structural characterization and gene localization of a new alpha chain variant.

We report the characterization of a new hemoglobin variant having a single amino acid substitution (Lys----Thr) at position 61 of the alpha chain. In addition to the structural analysis, we also describe the strategy used for the identification of the base substitution and the localization of the defect at the gene level using polymerase chain reaction and hybridization with allele-specific oligonucleotides.

Leptomeningeal plasmacytosis. Case report and considerations on treatment.

We describe a 68-year-old patient with a plasma cell leukaemia in haematological remission presenting with massive intracranial leptomeningeal plasmocytic infiltration (LPI) and hydrocephalus. He was treated with skull irradiation and a combination of intraventricular and lumbar intrathecal therapy with methotrexate. Neurologic improvement and clearance of plasma cells from the cerebrospinal fluid was reached after 2 weeks of treatment but prolonged follow-up was interrupted by a lethal gastro-intestinal haemorrhage, 6 weeks after starting the therapy. From previously reported cases it is known that LPI almost always occurs in either high-grade plasmocytomas or plasma cell leukaemia. These data suggest that therapy of LPI should be the same as in other leukaemias with leptomeningeal infiltration.

An identical translocation between chromosome 1 and 7 in three patients with myelofibrosis and myeloid metaplasia.

An identical chromosome abnormality was observed in three unrelated patients with meylofibrosis and myeloid metaplasia, two of the patients showing a history of polycythaemia vera (PV) before development of the myelofibrosis. Unstimulated peripheral blood cultures showed a translocation between chromosomes 1 and 7 replacing a homologue of pair 7. It was identified by G- and C-banding as t(1;7)(7pter leads to 7p11::1p1? leads to 1qter). While the first patient also showed trisomy 21 and the third patient had some extra material on the short arm of chromosome 17, all three had trisomy 1q and monosomy 7q. Although each of these abnormalities is frequently observed separately in various haematological disorders, the combination of the two in the form of an identical translocation in three patients is an example of induced non-random cytogenetic change in myelofibrosis.

Subacute combined degeneration of the spinal cord and the vitamin B12 metabolism, a clinical study.

In 28 patients suffering from subacute combined degeneration of the spinal cord, vitamin B12 metabolism was investigated. Two postulates, proving vitamin B12 deficiency and excluding another cause for the clinical symptoms, have to be fulfilled. Two patients had no disturbance in their vitamin B12 metabolism. Seven patients had a distinct vitamin B12 deficiency. In the remaining 19 patients we found a mild vitamin B12 deficiency. Of these patients, 5 had had a subtotal gastrectomy, one had had a low absorption of vitamin B12, and 13 patients we could not find a distinct cause for the vitamin B12 deficiency. It is not impossible that nutritional habits can be hold responsible for this deficiency. The question whether these 13 patients should be treated with vitamin B12 for the rest of their lives is difficult to answer. It is a conditio sine qua non that in the patients with S.C.D. the vitamin B12 metabolism is examined circumstantially. By so doing, it may be possible to detect, in cases with minor clinical signs and symptoms of S.C.D., the cause of their illness.

Studies on the effect of parenteral iron, Ferastral, an iron-poly(sorbitol-gluconic acid) complex, on blood coagulation in man.

The possible influence of Ferastral, an iron-poly(sorbitol-gluconic acid) complex, on blood coagulation in man was investigated. Ferastral added to plasma produced no changes in blood coagulation until a final concentration of 2 000 microgram/ml (35.8 mmol/1) was used, when minimal changes in blood coagulation factors were observed. Five patients were given an intramuscular injection of 250 mg Ferastral. No changes in blood coagulation and thrombocyte function were observed up to 5 hours after the initial iron injection.

Compensation for blood loss in plastic surgery with ferastral and autologous blood transfusion.

A study has been made to assess the effect on haematological status of pre-operative parenteral iron in a operation accompanied by conisderable blood loss. Forty-two patients who were to undergo breast reducing operations were selected for the trial. Patients were divided into three groups: group 1 which received no iron treatment, group 2 which received Ferastral, 250 mg Fe, 21 days before operation and group 3 which received Ferastral, 250 mg Fe, 21 days before operation plus an autologous blood transfusion during operation. The blood loss at operation which was estimated to be between 500 and 1 000 ml in 86% of the cases resulted in a decrease in haemoglobin in all groups. On the 14th postoperative day the decrease in Hb was significantly lower in both group 2 and 3 compared to group 1 (P less 0.05 and P less than 0.01, respectively). Forty per cent of the patients were anaemic in group 1, 10% in group 2 and 15% in group 3. It is concluded that the need for blood transfusion may be avoided in operations where the blood loss is less than 1 000 ml, provided sufficient iron is available for spontaneous blood replacement to take place.